Elsevier

European Urology

Volume 56, Issue 6, December 2009, Pages 903-910
European Urology

Platinum Priority – Bladder Cancer
Editorial by Vincenzo Serretta on pp. 911–913 of this issue
Clinical Outcome in a Contemporary Series of Restaged Patients with Clinical T1 Bladder Cancer

https://doi.org/10.1016/j.eururo.2009.07.005Get rights and content

Abstract

Objectives

To evaluate the indications for early and deferred cystectomy and to report the impact of this tailored approach on survival.

Design, setting, and participants

We retrospectively studied 523 patients seen at our institution who were initially diagnosed with T1 disease between 1990 and 2007.

Measurements

Variables analyzed included age, gender, multifocality, multifocal T1 disease, carcinoma in situ, grade, recurrence rate, and restaging status. End points were overall and disease-specific survival.

Results and limitations

A restaging transurethral resection (TUR) was performed in 523 patients. Of the patients who underwent restaging, 106 (20%) were upstaged to muscle-invasive disease and 417 patients were considered true clinical T1 (cT1); 84 of the latter group underwent immediate cystectomy. The median follow-up for survivors was 4.3 yr. The cumulative incidence of disease-specific death at 5 yr was 8% (95% confidence interval [CI], 5–13%), 10% (95% CI, 5–17%), and 44% (95% CI, 35–56%) for those restaged with lower than T1, T1, and T2 disease, respectively. Immediate cystectomy was more likely in patients with cT1 disease at restaging than in those with disease lower than cT1, but there were no other obvious differences in clinical characteristics between those with and without immediate cystectomy. Survival was not statistically different for patients who underwent an immediate cystectomy versus those who were maintained on surveillance with deferred cystectomy if deemed appropriate. Of 333 patients who did not undergo immediate cystectomy, 59 had a deferred cystectomy, and the likelihood of deferred cystectomy was greater in those with T1 disease on restaging TUR (hazard ratio: 2.40; 95% CI, 1.43–4.01; p = 0.001).

Conclusions

Restaging TUR should be performed in patients diagnosed with cT1 bladder cancer to improve staging accuracy. Patients with T1 disease on restaging are at higher risk of progression and should be considered for early cystectomy.

Introduction

Bladder cancer presents as non–muscle-invasive papillary tumors in 75–85% of cases [1]; 20% of such tumors invade the lamina propria (T1) [2]. Although both Ta and T1 tumors commonly recur, T1 cancers are potentially more lethal because 30–50% progress to muscle invasion or metastasis [3]. Multiple tumors, high-grade morphology, large (>3 cm) size, associated carcinoma in situ (CIS), lymphovascular invasion, depth of lamina propria penetration, and presence of tumor at first follow-up cystoscopy are associated with greater risk of stage progression and reduced survival [4], [5].

Management of T1 bladder cancer is a dynamic process. Some patients undergo immediate cystectomy while others are placed on long-term surveillance with the possibility of a deferred cystectomy. Although the choice of treatment takes into account several factors including multifocality, associated CIS, the presence of multifocal T1 disease, the presence of residual tumor at restaging transurethral resection (TUR), and prior history of bacillus Calmette-Guérin (BCG) treatment, there are no definite guidelines for selecting patients’ initial treatment. The objective of this study is to define the indications for early cystectomy or surveillance and to report the impact of this approach on survival.

Section snippets

Subjects and inclusion criteria

An institutional review board–approved, retrospective review of the institutional database was performed to identify patients with clinical T1 (cT1) transitional cell carcinoma (TCC) of the bladder. Diagnosis of cT1 disease was based on cystoscopy, bimanual examination, radiographic tests, and pathologic evaluation. Patients whose pathology slides were not available for review and patients with non-TCC were excluded; however, TCC with aberrant differentiation was included. All tumors were

Results

We identified 523 patients with cT1 TCC of the bladder who were restaged (Table 1). The diagnostic TUR was performed at Memorial Sloan-Kettering Cancer Center (MSKCC) for 144 patients (28%). The restaging TUR was performed at MSKCC for 83% of patients (435 of 523) and at an outside institution for the rest. Overall, 106 (20%) patients were upstaged to muscle-invasive disease. A similar proportion of patients were upstaged to T2 disease, regardless of where the restaging TUR was performed (21%

Discussion

Conservative management of T1 bladder cancer seeks to preserve the bladder while preventing death from progressive bladder cancer. It is a dynamic process that, to be successful, requires (1) careful selection of appropriate patients based on accurate initial pathologic staging and restaging with TUR; (2) identification of prognostic indicators, which include pathologic characteristics of the tumors, biologic markers, and the clinical response to BCG; and (3) adequate treatment, including

Conclusions

Conservative management of cT1 bladder cancer depends on careful selection and monitoring of patients. All patients being considered for conservative management should undergo restaging TUR to allow for better risk assessment. Patients with T1 disease on restaging are at high risk of progression and should be considered for early cystectomy.


Author contributions: Guido Dalbagni had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of

References (25)

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